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BCC NURSING207; 1400_Fluid__Electrolytes__and_Acid_Base_Imbalances_Practice_Questions with, Exams of Nursing

Barstow Community CollegeNursing

BCC NURSING207; 1400_Fluid__Electrolytes__and_Acid_Base_Imbalances_Practice_Questions with correct answers.

Typology: Exams

2025/2026

Available from 06/29/2026

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Targeted ATI Fluid, Electrolyte, and Acid-Base
1. A nurse is assessing a client who has dehydration. Which of the following assessments is the priority?
a. Skin turgor
i. The nurse should assess skin turgor to monitor the client's hydration status. Poor skin turgor is a
manifestation of dehydration. However, another assessment is the nurse's priority.
b. Urine output
i. The nurse should assess urine output to monitor the client's hydration status. Decreased urine output is
a manifestation of dehydration. However, another assessment is the nurse's priority.
c. Weight
i. The nurse should weigh the client because weight loss is a manifestation of dehydration. Decreased
weight is the best indication of the client's fluid status. However, another assessment is the nurse's
priority.
d. Mental status
i. The greatest risk to this client is injury from a fall due to a decline in their mental status. Therefore,
assessing the client's mental status is the nurse's priority.
2. A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values
should the nurse expect?
a. Hgb 20 g/dL
i. The nurse should identify that a client who has dehydration can have a Hgb level that is above the
expected reference range of 12 to 16 g/dL for females or 14 to 18 g/dL for males. Fluid volume excess
can cause hemodilution and a decreased hemoglobin level.
b. Hct 34%
i. The nurse should identify that a client who has fluid volume excess can have a Hct level that is below
the expected reference range of 37% to 47% for females or 42% to 52% for males. Fluid volume excess
can cause hemodilution and a decreased hematocrit level.
c. BUN 25 mg /dL
i. The nurse should identify that a client who has dehydration can have a BUN that is above the expected
reference range of 10 to 20 mg/dL. Fluid volume excess can cause a decrease in BUN.
d. Urine specific gravity 1.050
i. The nurse should identify that a client who has dehydration can have a urine specific gravity that is
above the expected reference range of 1.010 to 1.025. Fluid volume excess can cause a decrease in
urine specific gravity.
3. A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which
of the following laboratory values should the nurse report to the provider?
a. Sodium 128 mEq/L
i. This level is below the expected reference range of 136 to 145 mEq/L and is the likely cause of the
client's altered mental status. The nurse should report this finding to the provider and monitor the
client for weakened respiratory effort.
b. Potassium 4.8 mEq/L
i. This finding is within the expected reference range. However, the nurse should continue to monitor for
hypokalemia while the client is taking hydrochlorothiazide.
c. Calcium 9.1 mg /dL
i. This finding is within the expected reference range. However, the nurse should continue to monitor for
hypercalcemia while the client is taking hydrochlorothiazide.
d. Magnesium 2.0 mEq/L
i. This finding is within the expected reference range. However, the nurse should continue to monitor for
hypomagnesemia while the client is taking hydrochlorothiazide.
4. A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the
nurse include in the teaching as containing the lowest amount of magnesium?
a. One large, hard-boiled egg
i. One large, hard-boiled egg contains 5 mg of magnesium. Therefore, the nurse should recommend this
food as containing the lowest amount of magnesium.
b. 1 cup bran cereal
i. One cup of bran cereal contains 112 mg of magnesium. Therefore, the nurse should include a different
food as containing the lowest amount of magnesium.
c. ½ cup almonds
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Targeted ATI Fluid, Electrolyte, and Acid-Base

  1. A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? a. Skin turgor i. The nurse should assess skin turgor to monitor the client's hydration status. Poor skin turgor is a manifestation of dehydration. However, another assessment is the nurse's priority. b. Urine output i. The nurse should assess urine output to monitor the client's hydration status. Decreased urine output is a manifestation of dehydration. However, another assessment is the nurse's priority. c. Weight i. The nurse should weigh the client because weight loss is a manifestation of dehydration. Decreased weight is the best indication of the client's fluid status. However, another assessment is the nurse's priority. d. Mental status i. The greatest risk to this client is injury from a fall due to a decline in their mental status. Therefore, assessing the client's mental status is the nurse's priority.
  2. A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect? a. Hgb 20 g/dL i. The nurse should identify that a client who has dehydration can have a Hgb level that is above the expected reference range of 12 to 16 g/dL for females or 14 to 18 g/dL for males. Fluid volume excess can cause hemodilution and a decreased hemoglobin level. b. Hct 34% i. The nurse should identify that a client who has fluid volume excess can have a Hct level that is below the expected reference range of 37% to 47% for females or 42% to 52% for males. Fluid volume excess can cause hemodilution and a decreased hematocrit level. c. BUN 25 mg/dL i. The nurse should identify that a client who has dehydration can have a BUN that is above the expected reference range of 10 to 20 mg/dL. Fluid volume excess can cause a decrease in BUN. d. Urine specific gravity 1. i. The nurse should identify that a client who has dehydration can have a urine specific gravity that is above the expected reference range of 1.010 to 1.025. Fluid volume excess can cause a decrease in urine specific gravity.
  3. A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider? a. Sodium 128 mEq/L i. This level is below the expected reference range of 136 to 145 mEq/L and is the likely cause of the client's altered mental status. The nurse should report this finding to the provider and monitor the client for weakened respiratory effort. b. Potassium 4.8 mEq/L i. This finding is within the expected reference range. However, the nurse should continue to monitor for hypokalemia while the client is taking hydrochlorothiazide. c. Calcium 9.1 mg/dL i. This finding is within the expected reference range. However, the nurse should continue to monitor for hypercalcemia while the client is taking hydrochlorothiazide. d. Magnesium 2.0 mEq/L i. This finding is within the expected reference range. However, the nurse should continue to monitor for hypomagnesemia while the client is taking hydrochlorothiazide.
  4. A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium? a. One large, hard-boiled egg i. One large, hard-boiled egg contains 5 mg of magnesium. Therefore, the nurse should recommend this food as containing the lowest amount of magnesium. b. 1 cup bran cereal i. One cup of bran cereal contains 112 mg of magnesium. Therefore, the nurse should include a different food as containing the lowest amount of magnesium. c. ½ cup almonds

i. One-half cup of almonds contains 193 mg of magnesium. Therefore, the nurse should include a different food as containing the lowest amount of magnesium. d. 1 cup cooked spinach i. One cup of cooked spinach contains 157 mg of magnesium. Therefore, the nurse should include a different food as containing the lowest amount of magnesium.

  1. A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? a. Deep-tendon reflexes i. The nurse should assess the client's deep-tendon reflexes because this total serum calcium level is below the expected reference range of 9 to 10.5 mg/dL, and hypocalcemia can cause neuromuscular changes. However, there is another assessment the nurse should make first. b. Cardiac rhythm i. When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's cardiac rhythm because this total serum calcium level is below the expected reference range. Hypocalcemia can cause ECG changes, bradycardia, or tachycardia. c. Peripheral sensation i. The nurse should assess the client's peripheral sensation to check for paresthesia because this total serum calcium level is below the expected reference range, and hypocalcemia can cause neuromuscular changes. However, there is another assessment the nurse should make first. d. Bowel sounds i. The nurse should assess the client's bowel sounds to check for hypermotility because this total serum calcium level is below the expected reference range, and hypocalcemia can cause increased peristalsis. However, there is another assessment the nurse should make first.
  2. A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe? a. Dextrose 5% in 0.9% sodium chloride i. A sodium level of 155 mEq/L is an indication of hypernatremia. Dextrose 5% in 0.9% sodium chloride is a hypertonic solution. The nurse should anticipate a prescription for a hypotonic solution. b. Dextrose 5% in lactated Ringer’s i. A sodium level of 155 mEq/L is an indication of hypernatremia. Lactated Ringer's contains sodium and other electrolytes and is not indicated for hypernatremia. c. 3% sodium chloride i. A sodium level of 155 mEq/L is an indication of hypernatremia, and 3% sodium chloride is a hypertonic solution. The nurse should anticipate a prescription for a hypotonic solution. d. 0.45% sodium chloride i. A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution. The 0.45% sodium chloride is a hypotonic solution used to provide free water and treat cellular dehydration, which promotes waste elimination by the kidneys.
  3. A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? a. Hyperactive deep-tendon reflexes i. Hyperactive deep-tendon reflexes are an expected finding for a client who has hypomagnesemia. Other expected findings include muscle cramps, numbness, and tingling. b. Increased bowel sounds i. Decreased bowel sounds are an expected finding for a client who has hypomagnesemia. c. Drowsiness i. Insomnia is an expected finding for a client who has hypomagnesemia. d. Decreased blood pressure i. Increased blood pressure is an expected finding for a client who has hypomagnesemia.
  4. A nurse is assessing a client who has a phosphorous level of 2.4 mg/dL. Which of the following findings should the nurse expect? a. Hepatic failure i. This phosphorus level is below the expected reference range of 3 to 4.5 mg/dL. The nurse should assess a client who has hypophosphatemia for manifestations of kidney failure, not hepatic failure. b. Abdominal pain i. This phosphorus level is below the expected reference range. Hypophosphatemia causes weakness of skeletal muscles and rhabdomyolysis, which is acute muscle breakdown. It does not cause abdominal pain. c. Slow peripheral pulses

i. Ambulation can exacerbate the client's respiratory distress and is not appropriate at this time. c. Provide calming interventions i. The client's respiratory rate is above the expected reference range of 12 to 20/min. The nurse should instruct the client to breathe slowly. Calming the client should decrease the respiratory rate, which will cause the client's carbon dioxide levels to increase to expected levels of 35 to 45 mm Hg and lower the pH to expected levels of 7.35 to 7.45. d. Discontinue the PCA i. Discontinuing the PCA will not treat the underlying cause of the ABG results and could exacerbate the client's respiratory distress.

  1. A nurse is reviewing the medical record of a client who had diabetes mellitus and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? a. Urine output 30 mL/hr i. The expected reference range for urinary output is between 1,500 to 2,000 mL daily. A urinary output of less than 30 mL/hr, known as oliguria, can indicate dehydration, impaired renal blood flow, or renal failure. However, a urine output of 30 mL/hr does not need to be reported to the provider. b. Blood glucose 180 mg/dL i. A blood glucose level of 200 mg/dL or less is an indication that the client's diabetic ketoacidosis is resolving and is within the expect reference range for a casual glucose level. Therefore, the nurse does not need to report this finding to the provider. c. Serum potassium 3.0 mEq/L i. This serum potassium level is below the expected reference range. Hypokalemia is a serious complication that can occur when a client who has diabetic ketoacidosis is receiving insulin to treat the condition. The nurse should report this finding to the provider. d. BUN 18 mg/dL i. A BUN of 18 mg/dL is within the expected reference range. A BUN of 30 mg/dL or greater can occur due to dehydration for a client who has diabetic ketoacidosis.
  2. A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching? a. “If my stockings feel tight, I’ll just roll them down for a while.” i. The client should not roll the stockings down, because the rolled part can become a constricting band around the leg which can impede circulation. b. “I’ll put on my elastic stockings at the first sign of swelling.” i. The client should don graduated compression stockings upon awakening and remove them at bedtime. Wearing the stockings throughout the day prevents swelling of the extremities and improves circulation. c. “When I sit down to watch television, I’ll be sure to put my feet up.” i. Venous insufficiency makes it difficult for blood flow to return to the heart. Elevating the feet will increase venous return. The client should elevate their feet for at least 20 min several times per day. d. “It’s okay to cross my legs as long as it’s for less than an hour.” i. The client should not cross their legs. Doing so can further impair circulation of the lower extremities.
  3. A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the following foods should the nurse recommend as containing the greatest amount of potassium? a. ½ cup chopped celery i. One-half cup of chopped celery contains 132 g of potassium. Therefore, there is another food the nurse should recommend as containing the greatest amount of potassium. b. 1 cup plain yogurt i. One cup of plain yogurt contains 380 g of potassium. Therefore, the nurse should recommend this food as containing the greatest amount of potassium. c. One slice whole grain bread i. One slice of whole grain bread contains 60 g of potassium. Therefore, there is another food the nurse should recommend as containing the greatest amount of potassium. d. ½ cup cooked tofu i. One-half cup of cooked tofu contains 164 g of potassium. Therefore, there is another food the nurse should recommend as containing the greatest amount of potassium.
  4. A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? a. Confusion i. A client who has respiratory acidosis will experience confusion from a lack of cerebral perfusion. If acidosis is not reversed, the client's level of consciousness will decrease, and coma can occur.

b. Peripheral edema i. Peripheral edema is not a manifestation of respiratory acidosis. c. Facial flushing and warmth i. Facial flushing and warmth are manifestations of metabolic acidosis. Pale, cyanotic, dry skin is a manifestation of respiratory acidosis, as ineffective breathing causes a lack of perfusion to the tissues. d. Hyperreflexia i. Hyporeflexia, not hyperreflexia, is a manifestation of respiratory acidosis. As acidosis increases, hyperkalemia can occur, causing muscle weakness, flaccid paralysis, and hyporeflexia.

  1. A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer? a. Sodium polystyrene sulfonate 30 g/day i. Sodium polystyrene sulfonate is an electrolyte cation exchange medication that is given to treat hyperkalemia, not hypokalemia. b. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr i. This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5 to 10 mEq/hr, not to exceed 20 mEq/hr. The dilution should be 1 mEq of potassium chloride to 10 mL of 0.9% sodium chloride. c. Bumetanide 8 mg/day i. High-ceiling loop diuretics such as bumetanide are given to treat hyperkalemia, not hypokalemia. d. 100 mL of dextrose 10% in water with 10 units of insulin i. Dextrose 10% in water with 10 units of insulin is an IV solution given to treat hyperkalemia, not hypokalemia.
  2. A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mmhg, PaC02 56 mm hg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances. a. Respiratory acidosis i. Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO 2 , an elevated PaCO 2 , and an HCO 3 - within the expected reference range. These laboratory values indicate respiratory acidosis. b. Respiratory alkalosis i. The pH level is elevated above 7.45 in both respiratory and metabolic alkalosis. c. Metabolic acidosis i. With metabolic acidosis, the pH is less than 7.35 but the PaCO 2 is either within or below the expected reference range, and the HCO 3 - is decreased. d. Metabolic alkalosis i. The pH level is elevated above 7.5 in both respiratory and metabolic alkalosis.
  3. A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching? a. “I will eat more cheese because I can’t drink milk.” i. Cheese is a dairy product. If the client is allergic to milk, they will also be allergic to cheese. b. “I need to avoid foods with vitamin D because I am allergic to milk.” i. Vitamin D is necessary for calcium absorption and is unlikely to trigger an allergic reaction in a client who has a dairy allergy. c. “I will stop taking my calcium supplements if they irritate my stomach.” i. The nurse should recommend that the client prevent gastric upset by taking the calcium supplements with food. d. “I will add broccoli and kale to my diet.” i. The nurse should recommend that the client consume broccoli and kale, which are good sources of calcium, as alternatives to dairy products.
  4. A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? a. PaO i. The nurse should anticipate that a client who has respiratory alkalosis will have a PaO 2 level within the expected reference range of 80 to 100 mm Hg. b. PaCO i. The nurse should anticipate that a client who has respiratory alkalosis will have a decreased PaCO 2 level due to hyperventilation. c. Sodium

i. Although this sodium level is outside the expected reference range, it would not cause a prolonged PR interval and widened QRS complex. However, it can cause cerebral dysfunction. b. Chloride 102 mEq/L i. This chloride level is within the expected reference range. It would not result in a prolonged PR interval and widened QRS complex. c. Magnesium 1.8 mEq/L i. This magnesium level is within the expected reference range. It would not result in a prolonged PR interval and widened QRS complex. d. Potassium 6.1 mEq/L i. Hyperkalemia, defined as a potassium level above 5.0 mEq/L, can cause a prolonged PR interval, a wide QRS complex, flat or absent P waves, and tall, peaked T waves.

  1. A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis? a. pH 7.51, Pa02 94 mm hg, PaC02 38 mm hg, HCO3- 29 mEq/L. i. A pH above 7.45 is an indication of alkalosis b. pH 7.48, Pa02 89 mm hg, PaC02 30 mm hg, HCO3- 24 mEq/L. i. A pH above 7.45 is an indication of alkalosis c. pH 7.36, Pa02 77 mm hg, PaC02 52 mm hg, HCO3- 26 mEq/L. i. This pH value is within the expected reference range d. pH 7.26, Pa02 84mm hg, PaC02 38 mm hg, HCO3- 20 mEq/L. i. A pH below 7.35 is an indication of acidosis. An HCO3- below 22 mEq/L is an indication of metabolic acidosis
  2. A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first? a. Monitor the client’s bowel sounds i. An adverse effect of many diuretics, including furosemide, is hypokalemia. The nurse should monitor the client's bowel sounds for increased or decreased peristalsis due to hypokalemia. However, there is another action the nurse should take first. b. Review the client’s daily laboratory results i. An adverse effect of many diuretics, including furosemide, is hypokalemia. The nurse should review the client's daily laboratory results, especially the potassium level. However, there is another action the nurse should take first. c. Auscultate the client’s lungs i. An adverse effect of many diuretics, including furosemide, is hypokalemia. When using the airway, breathing, circulation approach to client care, the nurse should first auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles. d. Palpate the client’s peripheral pulses i. An adverse effect of many diuretics, including furosemide, is hypokalemia. The nurse should palpate the client's peripheral pulses to assess for cardiovascular changes, such as a thready and weak pulse. However, there is another action the nurse should take first.
  3. While reviewing a client's laboratory results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take? a. Implement seizure precautions i. The client is at risk for seizures due to low excitation threshold as a result of a decreased calcium level. The nurse should initiate seizure precautions to prevent injury. b. Administer phosphate i. Administering phosphate can further decrease the client's calcium level. c. Initiate diuretic therapy i. Diuretic therapy can further decrease the client's calcium level. d. Prepare the client for hemodialysis i. Hemodialysis is administered to treat hypercalcemia
  4. A nurse is preparing to administer oral potassium to a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? a. Administer a hypertonic solution i. A potassium level of 5.5 mEq/L indicates the client has hyperkalemia. This places the client at risk for bradycardia, hypotension, and life-threatening cardiac complications. The nurse should administer a hypertonic solution to correct the hyperkalemia, but another action is the priority. b. Repeat the potassium level

i. A potassium level of 5.5 mEq/L indicates the client has hyperkalemia. This places the client at risk for bradycardia, hypotension, and life-threatening cardiac complications. The nurse should repeat the potassium level to evaluate for effective treatment, but another action is the priority. c. Withhold the medication i. The greatest risk to the client is bradycardia, hypotension, and life-threatening cardiac complications due to hyperkalemia, defined as a potassium level above 5.0 mEq/L. Therefore, the nurse's priority action is to withhold the oral potassium and notify the provider. d. Monitor for paresthesia i. The nurse should monitor the client for paresthesia because numbness and tingling are indications of hyperkalemia, but another action is the priority.

  1. A nurse is evaluating a client who is receiving IV fluids to treat dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective? a. BUN 26 mg/dL i. A BUN of 26 mg/dL is above the expected reference range of 10 to 20 mg/dL. An elevated BUN is an indication that the client is still dehydrated. b. Sodium 142 mEq/L i. A sodium level of 142 mEq/L is within the expected reference range of 136 to 145 mEq/L and indicates that the fluid therapy has been effective. c. Hct 56% i. This Hct is above the expected reference range of 42 to 52% for males and 37 to 47% for females. An elevated Hct is an indication that the client is still dehydrated. d. Urine specific gravity 1. i. A urine specific gravity of 1.035 is above the expected reference range of 1.005 to 1.030. An elevated urine specific gravity is an indication that the client is still dehydrated. ATI Quiz Bank
  2. A nurse is providing teaching to a client who has heart failure and is taking spironolactone. Which of the following statements by the client indicates an understanding of the teaching? a. “I will increase my intake of citrus fruits, bananas, and potatoes.” i. Spironolactone is a potassium-sparing diuretic. Clients taking potassium-sparing diuretics should limit their intake of foods high in potassium due to the risk of hyperkalemia. b. “I will use salt substitutes on my food.” i. Clients who are taking potassium-sparing diuretics should not use salt substitutes because they contain potassium and place the client at risk for hyperkalemia. c. “I will drink as much water as I can while taking this medication.” i. Drinking large amounts of water can cause dilutional hyponatremia, which is dangerous when taking spironolactone since electrolyte imbalances, including hyponatremia, are common. d. “I will watch for increased breast tissue growth while taking this medication.” i. Spironolactone, which is derived from steroids, can cause adverse endocrine effects such as gynecomastia, impotence in men, and irregular menses and hirsutism in women. The nurse should instruct the client that these changes can occur.
  3. A nurse is reviewing the laboratory values for a 6-month-old infant who has acute renal failure. Which of the following findings should the nurse expect? a. BUN 5 mg/dL i. The nurse should expect an infant with acute renal failure to have an elevated BUN level. A BUN level of 5 mg/dL is within the expected reference range for an infant. b. Creatinine 0.2 mg/dL i. The nurse should expect an infant with acute renal failure to have an elevated creatinine level. A creatinine level of 0.2 mg/dL is within the expected reference range for an infant c. Sodium 125 mEq/L i. The nurse should expect an infant with acute renal failure to have hyponatremia. A sodium level of 125 mEq/L is below the expected reference range for an infant. d. Potassium 4.2 mEq/L i. The nurse should expect an infant with acute renal failure to have hyperkalemia. A potassium level of 4.2 mEq/L is within the expected reference range for an infant.
  4. A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect?

i. Hypernatremia is indicated by a sodium level greater than 145 mEq/L. The expected reference range for sodium is 136 to 145 mEq/L. Manifestations of hypernatremia include dry mucous membranes, agitation, thirst, hyperreflexia, and convulsions. It is not associated with chronic kidney disease. b. Hypomagnesemia i. Hypomagnesemia is indicated by a magnesium level below 1.3 mEq/L. The expected reference range for magnesium is 1.3 to 2.1 mEq/L. Hypomagnesemia is present in clients who have hyperthyroidism or diabetes and in clients who are pregnant. It is not associated with chronic kidney disease c. Hypercalcemia i. Hypercalcemia is indicated by a calcium level greater than 10.5 mg/dL. The expected reference range for calcium is 9.0 to 10.5 mg/dL. Hypercalcemia is present with some cancers, but it is not associated with chronic kidney disease. d. Hyperkalemia i. A client who has chronic kidney disease can have hyperkalemia, which is a potassium level greater than 5.0 mEq/L. The expected reference range for potassium is 3.5 to 5.0 mEq/L. Other manifestations of hyperkalemia can include palpitations, dysrhythmias, nausea, and muscle weakness.

  1. A nurse is assessing an older adult client for signs of dehydration. Which of the following findings is an expected part of the aging process? a. Elevation of urine specific gravity i. Creatinine clearance declines with age; therefore, the kidneys have a decreased ability to concentrate urine. This expected part of the aging process places the client at risk of dehydration. b. Decreased creatinine clearance i. Elevated urine specific gravity is an unexpected finding that could indicate dehydration. Normal specific gravity should range from approximately 1.010 to 1.020. Results obtained below this range indicate dilute urine, which is associated with overhydration and some medical conditions such as poorly controlled diabetes insipidus. Results obtained above this range indicate concentrated urine, which is associated with dehydration and some medical conditions such as poorly controlled diabetes mellitus. c. Dry oral mucous membranes i. Dry oral mucous membranes are an unexpected finding that could indicate dehydration. Other causes of dry mucous membranes include side effects of medications such as decongestants, diuretics, antihypertensives, antidepressants, and antihistamines; radiation therapy; or certain medical conditions such as Parkinson’s disease. d. Poor skin turgor over the sternum i. Poor skin turgor over the sternum is an unexpected finding that could indicate dehydration. Skin turgor is an abnormality in the skin’s ability to change shape and return to normal. Decreased skin turgor is a late sign of dehydration and is associated with moderate to severe dehydration. Fluid loss of 5% of the body weight is considered mild dehydration, 10% is moderate, and 15% or more is severe dehydration.
  2. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? a. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink i. This technique assesses capillary refill b. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back i. The nurse should use this technique to assess skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; in dehydration, the skin will remain tented. The nurse can also assess turgor by grasping a skinfold on the back of the forearm. c. Press the skin above the ankle for 5 seconds, release it, and note the depth of impression i. This technique determines the extent of a client’s pitting edema d. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers i. This technique determines a client’s body fat percentage
  3. A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? a. BUN 18 mg/dL i. This BUN falls within the expected reference range; therefore, it does not indicate hypovolemia. b. Capillary refill 1.5 sec i. This capillary refill time is within the expected reference range. With dehydration, it tends to be longer. c. Hct 55% i. An elevated hematocrit indicates hypovolemia. Other indications of hypovolemia are a weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output.

d. Urine specific gravity 1. i. This low urine specific gravity indicates hypervolemia, not hypovolemia.

  1. A nurse is assessing a client who has isotonic dehydration. Which of the following findings should the nurse expect? a. Increased hematocrit level i. The nurse should expect the client to have an increased hematocrit level due to hemoconcentration caused by reduced plasma fluid volume. b. Bradycardia i. The nurse should expect the client to have tachycardia to compensate for a decrease in blood pressure, which occurs as a result of reduced plasma fluid volume. c. Distended neck veins i. The nurse should expect the client to have flat neck veins as a result of reduced plasma fluid volume. d. Decreased urine specific gravity i. The nurse should expect the client to have an increased urine specific gravity due to concentrated urine as a result of reduced plasma fluid volume.
  2. A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (SATA) a. Jugular vein distention i. The increased venous pressure due to excessive circulating blood volume results in neck vein distension. b. Moist crackles i. Moist crackles are an indicator of pulmonary edema that can quickly lead to death. c. Postural hypotension i. Hypovolemia results in hypertension and tachycardia d. Increased heart rate i. Fluid volume excess (hypervolemia) is an expansion of fluid volume in the extracellular fluid compartment, which results in an increased heart rate and bounding pulses. e. Fever i. Fevers are common in clients who are experiencing dehydration, not fluid volume excess
  3. A nurse in an outpatient facility is assessing a client who is prescribed furosemide 40 mg daily. The client reports taking extra doses to promote weight loss. Which of the following findings should indicate to the nurse that the client is dehydrated? a. Urine specific gravity 1. i. Oliguria, an increased urine concentration, and an increased urine specific gravity greater than 1. are expected findings in clients who are dehydrated. b. Distended neck veins i. Distended neck veins are indicators of fluid volume excess, not dehydration or a fluid volume deficit. c. BUN 18 mg/dL i. Elevations in laboratory values such as BUN, hematocrit, and others can be seen in a client who is dehydrated. A BUN of 18 mg/dL is within the expected reference range. d. Bounding radial pulses i. Full, bounding radial pulses are an indicator of fluid volume excess, not dehydration or fluid volume deficit.
  4. A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? a. Elevated ST segments i. Elevated ST segments can indicate hyperkalemia and pericarditis b. Absent P waves i. Absent P waves can indicate atrial fibrillation and sustained ventricular tachycardia c. Depressed ST segments i. Depressed ST segments can indicate hypokalemia and ventricular hypertrophy d. Varying PP intervals i. Varying PP intervals indicate an irregular atrial rate and rhythm
  5. A nurse is reviewing the laboratory values of a client who has a positive Chvostek’s sign. Which of the following laboratory findings should the nurse expect? a. Decreased calcium i. Calcium is necessary for nerve conduction and muscle contractions. When the client’s total calcium level is <8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front

i. This potassium level is below the expected reference range, indicating hypokalemia. The nurse should report this finding to the provider for instructions about preventing muscle weakness that could affect respiration. c. Chloride 100 mEq/L i. This chloride value is within the expected reference range d. Magnesium 2.0 mEq/L i. This magnesium value is within the expected reference range

  1. A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? a. Hypokalemia i. Hyperkalemia is an expected finding for clients who has acute renal failure b. Hypercalcemia i. Hypocalcemia is an expected finding for clients who has acute renal failure c. Decreased plasma creatinine level i. An elevated plasma creatinine level is an expected finding for clients who has acute renal failure d. Metabolic acidosis i. Metabolic acidosis is an expected finding for clients who have acute renal failure
  2. A nurse is caring for a client who has chronic glomerulonephritis with oliguria. For which of the following electrolyte imbalances should the nurse monitor? a. Hypercalcemia i. The nurse should expect a client who has chronic glomerulonephritis with oliguria to have a calcium level at the lower end of or slightly below the expected reference range of 9 to 10.5 mg/dL. b. Hyperkalemia i. Oliguria resulting from chronic glomerulonephritis causes potassium retention, leading to levels above the expected reference range of 3.5 to 5 mEq/L. Other electrolyte imbalances common with this disorder affect sodium and phosphorus levels. Chronic glomerulonephritis eventually leads to end- stage kidney disease. c. Hypomagnesemia i. The nurse should expect a client who has chronic glomerulonephritis with oliguria to have a magnesium level within the expected reference range of 1.3 to 2.1 mEq/L. The major electrolyte imbalances common with this disorder affect potassium, sodium, and phosphorus levels. d. Hypophosphatemia i. The nurse should expect a client who has chronic glomerulonephritis with oliguria to have a phosphorous level above the expected reference range of 3 to 4.5 mg/dL.
  3. A nurse is checking the laboratory values of a client who has chronic kidney disease. The nurse should expect elevations in which of the following values? a. Potassium and magnesium i. Clients who have chronic kidney disease have hyperkalemia, hyperphosphatemia, and hypermagnesemia as well as elevations in serum creatinine and blood urea nitrogen. b. Calcium and bicarbonate i. Serum levels of calcium and bicarbonate decrease in clients who have chronic kidney disease. c. Hemoglobin and hematocrit i. Hemoglobin and hematocrit decrease in clients who has chronic kidney disease d. Arterial pH and PaCO i. Arterial pH decreases or remains at expected levels, and PaCO2 decreases in clients who have chronic kidney disease
  4. A nurse is reviewing a client’s laboratory report. The client’s ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? a. Respiratory alkalosis i. This client’s pH is elevated above the expected reference range of 7.35 to 7.45, indicating alkalosis. Additionally, the client’s PaCO2 is below the expected reference range of 35 to 45 mmHg, which indicates a respiratory origin. Hence, the nurse should conclude that the client’s elevated pH and decreased PaCO2 indicate respiratory alkalosis. b. Metabolic acidosis i. ABGs are drawn to determine the acid-base balance in the arterial blood. Acidosis is determined by measuring a pH lower than the expected reference range of 7.35 to 7.45. This client has a pH of 7.5 and therefore does not have acidosis. c. Respiratory acidosis

i. This client’s pH is elevated above the expected reference range of 7.35 to 7.45. Acidosis is presented by a lower pH, usually below 7.35. d. Metabolic alkalosis i. Metabolic origin is determined by examining the HCO3- levels. The client’s bicarbonate is within the expected reference range of 22 to 26 mEq/L.

  1. A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? a. Respiratory alkalosis i. Respiratory alkalosis occurs when a client exhales too much carbon dioxide. Clients who hyperventilate often experience this complication. b. Respiratory acidosis i. Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs. c. Metabolic alkalosis i. Metabolic alkalosis occurs when a client has an excess of bicarbonate. Clients who use bicarbonate of soda as an antacid are at risk of developing metabolic alkalosis. Excessive vomiting also places a client at risk of developing metabolic alkalosis. d. Metabolic acidosis i. Metabolic acidosis occurs when a client has a decrease in bicarbonate. Clients who have severe diarrhea or kidney failure are at risk of developing metabolic acidosis.
  2. A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect? a. pH 7.31, HCO3- 22 mEq/L, PaCO2 50 mm Hg i. The laboratory values reflect respiratory acidosis b. pH 7.48, HCO3- 23 mEq/L, PaCO2 25 mm Hg i. These laboratory values reflect respiratory alkalosis c. pH 7.32, HCO3- 18 mEq/L, PaCO2 40 mm Hg i. These laboratory values reflect metabolic acidosis d. pH 7.49, HCO3- 32 mEq/L, PaCO2 40 mm Hg i. The nurse should identify that these laboratory values reflect metabolic alkalosis. The pH and bicarbonate values are greater than the expected reference range, and the PaCO2 is within the expected reference range.
  3. A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO 27 mmHg, and HCO3- 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? a. Respiratory acidosis i. Respiratory acidosis reflects an increase in carbon dioxide resulting from inadequate excretion and an increase in the hydrogen ion level (i.e. decreased pH) of the blood. Common causes of this acid-base imbalance are airway obstruction and respiratory depression. b. Metabolic acidosis i. Metabolic acidosis results from a metabolic disturbance such as diabetic ketoacidosis or excessive ingestion of alcohol or salicylates, not a respiratory problem. c. Respiratory alkalosis i. Because of rapid breathing, the client is exhaling excessive amounts of carbon dioxide. This loss of carbon dioxide decreases the hydrogen ion level of the blood, which causes the pH to increase and results in respiratory alkalosis. d. Metabolic alkalosis i. Metabolic alkalosis results from a metabolic disturbance such as prolonged vomiting or excessive nasogastric suctioning, not a respiratory problem.
  4. A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? a. Respiratory alkalosis i. With respiratory alkalosis, the pH is elevated b. Metabolic alkalosis i. With metabolic alkalosis, the pH is elevated c. Respiratory acidosis i. With respiratory acidosis, the PaCO2 is elevated d. Metabolic acidosis

a. Hemoglobin 10 g/dL i. This laboratory value is below the expected reference range. The nurse should anticipate an elevated hemoglobin level during the resuscitation phase due to the loss of fluid volume. b. Sodium 132 mEq/L i. This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space. c. Albumin 3.6 g/dL i. This laboratory finding is within the expected reference range. The nurse should anticipate a low albumin level during the resuscitation phase. d. Potassium 4.0 mEq/L i. This laboratory finding is within the expected reference range. The nurse should anticipate an elevated potassium level during the resuscitation phase.

  1. A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? a. Calibrate the scales weekly i. The nurse should calibrate the scales to 0 each day or before each use to provide accurate information b. Use a different scale each time i. The nurse should weigh the client using the same scale each time because there generally is a slight difference between readings from each scale. c. Weigh the client on arising i. The nurse should weigh the client on arising each day, after voiding, and before breakfast. An accurate weight requires the client to be weighed wearing the same garments and on the same carefully calibrated scale (balanced to 0 before each use). Accurate daily weights provide the easiest measurement of volume status. An increase of 1 kg (2.2 lb) is equal to 1,000 mL (1 L) of retained fluid. d. Weigh the client without clothing i. The nurse should plan to have the client's weight taken wearing the same type of clothing each day to provide an accurate reading and to avoid embarrassment.
  2. A nurse is assessing a client who has fluid-volume excess. Which of the following findings should the nurse expect? a. Crackles in the lung fields i. Manifestations of fluid-volume excess include crackles in the lungs, dependent edema, full neck veins when the client is upright, elevated blood pressure, and sudden weight gain. b. Flat neck veins i. Flat neck veins when the client is supine are a manifestation of fluid-volume deficit, not fluid-volume excess c. Postural hypotension i. Postural hypotension is a manifestation of fluid-volume deficit, not fluid-volume excess. d. Dark yellow urine i. Dark yellow urine is a manifestation of fluid-volume deficit, not fluid-volume excess.
  3. A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? a. Sodium i. Sodium regulates extracellular fluid balance, nerve impulse transmission, acid-base balance, and various other cellular activities. b. Calcium i. Calcium supports bone and tooth formation and facilitates nerve impulse transmission. However, it does not affect extracellular fluid volume. c. Potassium i. Potassium affects storage of glycogen, nerve impulse transmission, cardiac conduction, and smooth muscle contraction. However, it does not affect extracellular fluid volume. d. Magnesium i. Magnesium affects enzyme and neurochemical activities and the excitability of cardiac and skeletal muscles. However, it does not affect extracellular fluid volume.
  4. A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? a. Decreased urine specific gravity i. An increase in urine specific gravity should indicate to the nurse that the client is experiencing fluid volume deficit. b. Increased heart rate

i. An increased heart rate should indicate to the nurse that the client is experiencing fluid volume deficit. Other findings can include an increased BUN level, dry mucous membranes, and dark yellow urine. c. Decreased hematocrit i. An increased hematocrit should indicate to the nurse that the client is experiencing fluid volume deficit. d. Increased skin turgor i. Poor skin turgor should indicate to the nurse that the client is experiencing fluid volume deficit.

  1. A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? a. Weight gain of 1 kg (2.2 lb) in 1 day i. A weight gain of 1 kg (2.2 lb) in 1 day indicates that the client is retaining fluid and is at risk of fluid volume overload. This suggests the client's heart failure is worsening. b. Pitting edema + i. Pitting edema (a visible finger indentation after application of pressure) alerts the nurse that the client has retained fluid and indicates fluid in the client's tissues. Pitting edema is rated on a scale of mild (+1) to severe (+3). Pitting edema of +3 suggests the client has developed fluid volume overload and worsening heart failure. c. Client report of nocturnal cough i. A client who is in the early stages of heart failure might report a cough that is irritating, occurs at night, and is nonproductive. d. B-type natriuretic peptide (BNP) level of 100 pg/mL i. BNP levels increase as a result of the ventricular hypertrophy in heart failure. A BNP level above 100 pg/mL is indicative of heart failure. Levels continue to increase with the severity of the condition.
  2. A nurse in a provider’s office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess? a. Sunken eyeballs i. Sunken eyeballs are a clinical manifestation of fluid volume deficit b. Hypotension i. Hypotension is a clinical manifestation of fluid volume deficit c. Poor skin turgor i. Poor skin turgor is a clinical manifestation of fluid volume deficit d. Bounding pulse i. A bounding pulse is an expected finding of fluid volume excess Test Bank: Fluid, Electrolyte, and Acid-Base Imbalances
  3. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. Blood pressure is 90/40 mm Hg. i. The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss due to the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient’s fluid intake but not as urgently as the hypotension b. Urine output is 30 mL over the last hour. c. Oral fluid intake is 100 mL for the last 8 hours. d. There is prolonged skin tenting over the sternum.
  4. A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level of 120 mg/dL i. Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention. d. Total urinary output of 280 mL during past 8 hours

i. IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias. c. Only give the KCl through a central venous line. d. Discontinue cardiac monitoring during the infusion.

  1. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. i. Because the patient’s gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer’s solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.
  2. A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO 2 85 mm Hg, PaCO 2 32 mm Hg, and HCO 3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis i. The pH indicates that the patient has alkalosis and the low PaCO 2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO 3.
  3. The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Start the prescribed PRN oxygen at 2 to 4 L/min. c. Administer the prescribed normal saline bolus and insulin. i. The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis. d. Encourage the patient to take deep, slow breaths with guided imagery.
  4. An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor b. Edema i. The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels. c. Confusion d. Restlessness
  5. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds i. Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation. b. Urinary output c. Peripheral pulses d. Peripheral edema
  1. The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased peripheral edema i. Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient’s protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status. d. Blood pressure 110/72 mm Hg
  2. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO 2 88 mm Hg, PaCO 2 37 mm Hg, and HCO 3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis i. The pH and HCO 3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses. b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
  3. A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Oral digoxin (Lanoxin) 0.25 mg daily i. Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level. b. Ibuprofen (Motrin) 400 mg every 6 hours c. Metoprolol (Lopressor) 12.5 mg orally daily d. Lantus insulin 24 U subcutaneously every evening
  4. The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Monitor for Trousseau’s and Chvostek’s signs. d. Encourage fluid intake up to 4000 mL every day. i. To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau’s and Chvostek’s signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.
  5. When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray? a. Grape juice b. Milk carton i. Foods high in phosphate include milk and other dairy products, so these are restricted on low- phosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in phosphate and are not restricted. c. Mixed green salad d. Fried chicken breast
  6. A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a. Daily alcohol intake i. Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium levels. b. Intake of dietary protein c. Multivitamin/mineral use d. Use of over-the-counter (OTC) laxatives
  7. A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate?